GYNECOLOGIC

4, 255-258(1976)

ONCOLOGY

Carcinoma

of the Uterine WILSON

Ministry

Cervix

I. B. ONUIGBO,

of Health, General Hospital, Received

January

in Nigerian

lgbos

PH.D. Enugu, Nigeria

14, 1976

Invasive carcinoma of the uterine cervix was studied in 13 I Nigerian Igbo women. About half of them were premenopausal. The average parity was 6.4. The growth occurred during pregnancy in four women. Vaginal bleeding was the most common symptom and most patients presented with advanced growths. There were 116 squamous carcinomas, 11 adenocarcinomas, 3 adeno-acanthomas, and 1 undifferentiated carcinoma. Although Igbo males are circumsized, cervical carcinoma is common in Igbo females, outnumbering mammary carcinoma in the present series. Accordingly, Igbo findings accord with recent evidence that the circumcision status of male partners does not correlate with the incidence of cervical carcinoma.

A salient feature of the geographic pathology of uterine cervical carcinoma is the rarity of the disease in Jewish women [1,21. Naturally, this has led to both speculation and investigation. One Jewish custom, namely, male circumcision [3], has been of particular interest. Basden [41, who lived among the Igbos of Nigeria for 35 years, devoted a chapter of his anthropologic work to the similarities between this ethnic group and the Jews. He wrote: “Coming to more intimate practices, we find a number of similarities which are associated with life. Beginning with the infant, we have Circumcision. This rite is normally carried out on the eighth day after birth as in the case of the Israelites.” Therefore, a study of uterine cervical carcinoma in this ethnic group appears worthy of record. INVESTIGATION

The cervical carcinomas which constituted the materials for this study were obtained either by biopsy or from operative specimens. Penile and mammary carcinomas were also studied. All specimens were received by me at a central laboratory which serves the numerous government, mission, and private hospitals in Igboland. All doctors are free to send me surgical specimens for histologic examination, the sole condition being the submission of fairly full clinical summaries. These summaries and my own diagnoses have been analyzed. RESULTS Proportional rates. From February 1970 through November 1975, 28 doctors working in 20 hospitals submitted 126 biopsy and 5 hysterectomy specimens from 131 Igbo women suffering from invasive cervical carcinoma. Specimens of mammary carcinoma from 104 women were also received. As regards cancer of the penis, one case each involved the shaft and the glans while two other cases affected the root. 255 Copyright @ 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.

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WILSON

I. B. ONUIGBO

Age. Table 1 shows that the cases occurred frequently in the younger age groups. The average age at diagnosis was 46.3 years. TABLE 1 AGE DISTRIBUTION Patients

Age group 20-29 30-39 40-49 50-59 60-69 70

6 35 29 37 23 1

Total

131

Pregnancy. The parity of the patients was not stated in 10 cases. For the remaining 121 cases, the parity pattern is shown in Table 2. The average parity was 6.4. Four patients were pregnant at the time of diagnosis, two of them being at term. TABLE 2 PARITY DISTRIBUTION Parity Patients

0 1

1 4

2 5

3 8

4 4

5 13

6 22

7 22

8 19

9 14

10 7

11 2

Unstated 10

Symptoms. Vaginal bleeding was the most common symptom, being recorded in 118 cases. It was expressly stated to have been postmenopausal in 50 cases. However, assuming the average age at menopause to be 48 years [5], there were 11 other women whose bleeding was also probably postmenopausal. Consequently, 70 patients were still premenopausal when this symptom started. The next most common symptom was vaginal discharge (34 cases). Pain was mentioned in 21 cases. The other symptoms of any magnitude were dysuria and hematuria which occurred in 4 and 3 cases, respectively. Clinical sruge. This was supplied in only 3 1 cases but could be deduced from the clinical summaries in a further 29 cases. These 60 cases were staged as follows: II, 25; III, 20; and IV, 15. Histology. In 116 cases were squamous carcinomas, all but a few showing readily discernible keratinization. Of the remaining 15 cases, there were 11 adenocarcinomas, 3 adenoacanthomas, and 1 undifferentiated carcinoma. Associated conditions. Squamous carcinomas were associated with some notable conditions. It was the tumor type seen in the cervical stump of a woman 6 years after subtotal hysterectomy for an undisclosed illness. In another patient, it arose 8 years after her breast had been removed for what was almost certainly another carcinoma. Decubitus ulcer was queried in one patient with procidentia, but malignancy ‘was discovered at microscopy. Carcinoma extended from the cervix to involve a polyp in another patient.

CARCINOMA

OF THE

UTERINE

CERVIX

257

DISCUSSION Although Igbo males are circumcized, Igbo females appear to suffer commonly from cervical carcinoma. Thus, unlike the trend in other parts of the world [6,7], cervical carcinomas outnumbered mammary carcinomas in Igbo women. Accordingly, the frequency of cervical carcinomas in the Igbos supports recent evidence [3,8] which seems to show that there is no association between the circumcision status of male partners and the occurrence of this genital cancer. A broad correlation was found in Uganda [9] between the incidence of cervical cancer and penile cancer in the different ethnic groups. From my data, it is evident that the apparently high frequency of cervical carcinoma in Igbo women contrasts sharply with the apparent rarity of penile carcinoma in Igbo men. As in other series [ 11, some guide to the etiology of cervical carcinoma is obtained from the parity of the present patients. My findings compare well with those of Guido and Lindo [lo] in Nicaraguan women in whom “the onset of cervical carcinoma was in direct proportion to the number of pregnancies and parity.” Three percent of Igbo women with cervical carcinoma presented during pregnancy. As Hawks [ 111has stressed, there is need for early diagnosis and good management of this special class of patients. According to Ed&ton and Gilles [12], premenopausal women are frequently affected by cervical carcinoma in the tropics. This is true of the Igbos. As elsewhere [53, bleeding was the only symptom of high frequency. Unfortunately, most of the present patients neglected it. As a result, their growths were usually so advanced that the clinicians were apt to describe them portentously with such expressions as “fungating lesion grossly replacing cervix” and “excavating lesion replacing cervix.” Clearly, there is need for health education in this ethnic group, as in other underprivileged groups [133. In conclusion, what are the future prospects? For instance, with regard to such factors as exposure to sexually transmitted infection [14] and age at first coitus and marriage [ 151,no data are available in the present study. It is to be hoped that future work, using advanced epidemiologic techniques, will provide further information. REFERENCES 1. Kessler, I. I. Perspectives on the epidemiology of cervical cancer with special reference to the herpesvirus hypothesis, Cancer Res. 34, 1091-1110 (1974). 2. MacMahon, B., and Pugh, T. F. Epidemiology, Little Brown, Boston, p. 117 (1970). 3. Thomas, D. B. An epidemiologic study of carcinoma in situ and squamous dysplasia of the uterine cervix, Amer. J. Epidemiol. 98, 10-28 (1973). 4. Basden, G. T. Niger Zbos, Frank Cass, London, p. 417 (1966). 5. Corscaden, J. A. Gynecologic cancer, Williams & Wilkins, Baltimore pp. 160 and 522 (1962). 6. Cramer, D. W., and Cutler, S. J. Incidence and histopathology of malignancies of the female genital organs in the United States, Amer. J. Obster. Gynecol. 118, 443-460 (1974). 7. Nielson, I. C., et al. Carcinoma of the uterine cervix, Cancer 20, 8692 (1967). 8. Terris, M., Wilson, P., and Nelson, J. H. Relation of circumcision to cancer of the cervix, Amer. I J. Obstet. Gynecol. 117, 10X-1066 (1973). 9. James, P. D., Taylor, C. W., and Templeton, A. C. Tumours of the female genitalia, in Tumours in a Tropical Country, Springer, Berlin, pp. 108-109 (1973). 10. Guido, C., and Lindo, J. J. Analysis of 600 cases of cervical carcinoma, Znt. Surg. 59, 167-168 (1974).

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11. Hawks, B. L. Diagnosis of cervical cancer in the pregnant patient, J. Arkansas Med. Sot. 70, 204-205 ( 1973). 12. Edington, G. M., and Gilles, H. M. Pathology in the Tropics Arnold, London, p. 546 (1969). 13. Felts, S. K., Utterback, L. R., and Ramsay, R. C. Cancer of the cervix uteri in Arkansas, J. Arkansas Med. Sot. 70, 206-207 (1973). 14. Beral, V. Cancer of the cervix: A sexually transmitted infection? Lnncer 1, 1037-1040 (1974). 15. Dickinson, L. E. Control of cancer of the uterine cervix by cytologic screening. Gynecol. Oncology 3, 1-9 (1975).

Carcinoma of the uterine cervix in Nigerian Igbos.

GYNECOLOGIC 4, 255-258(1976) ONCOLOGY Carcinoma of the Uterine WILSON Ministry Cervix I. B. ONUIGBO, of Health, General Hospital, Received Ja...
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